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Medical Power of Attorney Forms | Living Wills

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A medical power of attorney form, or “advance directive” or “health care proxy”, is a form that allows a person to elect someone else to handle their health care decisions only if they are not able to do so. This is common for elderly individuals or those with dementia or Alzheimer’s disease. Although, this may be for any person who is considered incapacitated.

Signing Requirements -Depending on the State, it may be required to sign with either two (2) witnesses, a notary public, or both.

Table of Contents

By State

Signing Requirements

STATE SIGNING REQUIREMENTS LAWS
 Alabama Two (2) Witnesses § 22-8A-4(c)(4)
 Alaska Notary Public or Two (2) Witnesses AS 13.52.010(b)
 Arizona Notary Public or One (1) Witness § 36-3221(A)(3)
 Arkansas Notary Public or Two (2) Witnesses § 20-6-103(c)
 California Notary Public or Two (2) Witnesses § 4701(e)
 Colorado No law (Notary Public recommended)

§ 15-14-506

 Connecticut Two (2) Witnesses § 19a-575
 Delaware Two (2) Witnesses § 2503(b)(1)(d)
 Florida Two (2) Witnesses § 765.202(1)
 Georgia Two (2) Witnesses § 31-32-5
 Hawaii Notary Public and Two (2) Witnesses § 327E-3(1)
 Idaho No law (Notary Public recommended) § 39-4510
 Illinois One (1) Witness 755 ILCS 45/4-5.1
 Indiana One (1) Witness § 16-36-1-7(b)(3)
 Iowa Notary Public or Two (2) Witnesses § 144B.3(b)
 Kansas Notary Public and Two (2) Witnesses § 58-632
 Kentucky Notary Public or Two (2) Witnesses § 311.625(2)
 Louisiana Two (2) Witnesses § 224 (A)
 Maine Two (2) Witnesses § 5-803(2)
 Maryland Two (2) Witnesses § 5–603
 Massachusetts Two (2) Witnesses § 201D-2
 Michigan Two (2) Witnesses § 700.5506(4)
 Minnesota Notary Public or Two (2) Witnesses § 145C.03(5)
 Mississippi Notary Public or Two (2) Witnesses § 41-41-205(2)
 Missouri Notary Public § 404.705(3)
 Montana Two (2) Witnesses § 50-9-103
 Nebraska Notary Public or Two (2) Witnesses § 30-3404(5)
 Nevada Notary Public or Two (2) Witnesses NRS 162A.790
 New Hampshire Notary Public or Two (2) Witnesses § 137-J:14
 New Jersey Notary Public or Two (2) Witnesses § 26:2H-56
 New Mexico Two (2) Witnesses § 24-7A-4
 New York Two (2) Witnesses PBH § 2981
 North Carolina Notary Public and Two (2) Witnesses § 32A-16A(3)
 North Dakota Notary Public or Two (2) Witnesses § 23-06.5-05(d)
 Ohio Notary Public or Two (2) Witnesses § 1337.12(1)(b)
 Oklahoma Two (2) Witnesses 63 O.S. § 3101.4(A)
 Oregon Notary Public or Two (2) Witnesses § 127.515(2)
 Pennsylvania Two (2) Witnesses § 5452(b)(2)
 Rhode Island Notary Public or Two (2) Witnesses § 23-4.10-2(9)
 South Carolina Notary Public and Two (2) Witnesses § 62-5-517
 South Dakota Notary Public or Two (2) Witnesses § 34-12D-2
 Tennessee Notary Public or Two (2) Witnesses § 34-6-203(a)(3)
 Texas Two (2) Witnesses § 166.154
 Utah One (1) Witness § 75-2a-107(c)
 Vermont Two (2) Witnesses § 9703(b)
 Virginia Two (2) Witnesses § 54.1-2983
 Washington Notary Public or Two (2) Witnesses § 11.125.050
West Virginia Notary Public and Two (2) Witnesses § 16-30-4(a)
 Wisconsin Two (2) Witnesses § 155.10(1)(c)
 Wyoming Notary Public or Two (2) Witnesses § 35-22-403(b)

How to Get Medical POA

Step 1 – Select Your Agent

The Agent that you select will have the responsibility of making your decisions based on your health care situation. Therefore you will want someone that you trust and is aware of your basic medical history (such as heart conditions, medication, allergies, etc.)

  • Successor (2nd) Agent – Individual selected only if the primary agent is not able to fulfill their duties. Co-agent authority is not usually allowed, must be the decision of 1 person.
  • Compensation – You have the option to set up compensation for the agent selected for lodging, food, and travel costs.

Step 2 – Agent’s Decisions

The decisions you give your agent related to your health care is up to you. You can allow your agent to make any type of decision that presents itself or you could limit your agent to only certain types of decision making. The more detailed you are as to what your agent can and cannot do will enhance the medical staff on your health intentions.

  • Example –  Requesting the agent to refuse life support if there is little to no chance of a full recovery.

The following powers of the agent should be written:

  • Surgical Treatments
  • Nursing Home Treatment/Care
  • Hospitalization
  • Medical Treatment
  • Psychiatric Treatment
  • HomeStay Care
  • Organ Donation
  • End of Life Decisions

Step 3 – Attach a Living Will

A living will is a highly recommended option to be attached to any medical power of attorney. In addition to having someone speak on their behalf, a living will outlines a person’s end of life treatment selections.

For example, if a person should become in an incapacitated state with no chance for a cure, they can select to withhold life-sustaining methods to keep them alive. In addition, it allows the selection for organ donation and other post-death options.

Step 4 – Sign & Complete

The Principal and Agent must sign in accordance with their respective State Signing Laws. In most cases, the form may be signed in the presence of two (2) witnesses or notary public, and sometimes both. After this has been legally authorized the document becomes valid to be used. The Principal must be thinking freely during the creation of this form.

The Agent should carry an original copy of their form and will most likely need to present it during every occurrence. It is recommended to give a copy of this form to your primary care physician.

When to Use a Medical POA

A medical power of attorney is commonly used for:

  • Elderly parents;
  • Individuals suffering from Alzheimer’s, Dementia, or other mental illness;
  • Those seeking risky surgery in the near future; and
  • Any person who may become in a life-threatening situation.

Incapacitated Without a Medical Power of Attorney

If a person becomes incapacitated without a medical power of attorney typically their spouse or close family member will be able to speak on their behalf with hospital staff. Legally speaking, guardianship rights would have to be applied for in the person’s local jurisdiction.

Medical POA vs Living Will

A Medical (Health Care) Power of Attorney allows an individual to give someone else the right to make decisions about their end of life treatment options while guiding their intentions in the form.

Living Will lets a person establish end-of-life plans without the use of a surrogate to help guide medical staff as to their wishes. The instructions written are to be followed by the patient’s primary care physician and cannot be changed by friends or family.

(Video) What is a Medical Power of Attorney?

How to Write a Medical POA

Download in Adobe PDF (.pdf), Microsoft Word (.docx), or Open Document Text (.odt).

To write a medical power of attorney the principal, or person granting power, will have to elect someone to handle their health care decisions (along with up to two (2) ‘secondary’ or ‘alternate’ agents in the chance the first does not show). Once a representative has been decided to begin by filling in the following:

Step 1 – In Section I (Appointment of Health Care Agent) the Principal and Agent full name and address. At the bottom of the section, the home phone, work phone, cell phone, and e-mail of the agent should be written.

medical-power-of-attorney-appointment-of-agent

Step 2 – In Section II the principal should include any exceptions (if any) from the broad powers the agent will have.

medical-poa-limitations-on-agent

Step 3 – In Section III, the principal has the option of selecting up to two (2) alternate agents in the chance individuals are unavailable for an act for the principal.

medical-poa-alternate-secondary-agent

Step 4 – In Section IV list the locations where originals and copies of this document will be held.

medical-poa-original-copies-where-held-location

Step 5 – In Section V, if the power of attorney will have an end period check the box and initial with the date that the form expires.

medical-poa-duration

Step 6 – On the last two (2) pages the individuals listed should sign the form in the presence of a notary public and/or two (2) witnesses that are not in any way connected (blood/marriage) with the parties authorizing the form.

  • Notary Public

All parties of the document must be present with the Notary Public.

medical-poa-notary-acknowledgment

  • Two (2) Witnesses

If the State requires two (2) witnesses then the Witness Acknowledgment must be signed on the last page.

medical-poa-witness-statement-acknowledgment

 

Laws by State


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